Velev G, Gribnev P, Todorov G, Dapri G
Clinic of Surgery & Department of Surgery, Alexandrovska University Hospital, Sofia, Bulgaria.
Khirurgiia (Sofiia). 2013(2):38-43.
The laparoscopic surgery of colon increasingly replaces the conventional surgery of colon on a global and regional scale. Many randomized studies demonstrate the advantages with regard to the shorter postoperative hospital stay, faster recovery, and identical results of the indexes of survival and frequency of relapses. The en bloc resection in cases of locally advanced colon cancer is the most secure method for achieving of R0 resection . The growth of the tumoral mass towards the adjacent structures manifests with histological tumor invasion in approximately 50% of the cases. The cases of laparoscopic en bloc resection for the treatment of colorectal cancer, which are described in the literature, increase. In this report we present a clinical case of substenotic sigmoid colon cancer and perioperative finding of infiltration towards a small intestinal loop and part of the urinary bladder, as well as towards the left uterine tube and the left adnex. In the case of this patient laparoscopic en bloc resection of the tumor formation was performed according to the so called "laparoscopic no touch technique". Approximately 15-20% of the cases of colorectal cancer are still in T4 stage, with involvement of the adjacent organs (1), despite the advance of the examination methods.
A 67 year old female was admitted to the hospital for a substenotic sigmoid colon lesion, syndrome of anemia, resulted adenocarcinoma at colonoscopy. Endoscopy showed an endoluminal tumor at 25 cm from the anal margin and preoperative work-up did not evidence any secondary lesions or invasion of other organs.
Four abdominal trocars were placed. The laparoscopic exploration of the abdominal cavity showed the presence of a colic mass with suspected invasion of a small bowel loop and part of the urinary bladder, the left uterine tube, and the left ovary. The tumor formation was dissected en bloc with resection of the left uterine tube and ovary, the urinary bladder, and a small bowel loop. Colorectal anastomosis with laparoscopic manual technique was performed. The anastomosis was tested for leak-tightness. The specimen was removed by enlargenemt of the 5 mm. suprapubic trocar.
The mean operative time was 285 minutes with blood loss of 300 ml. Patient was discharged on Postoperative Day 5. The histological result verified tumoral invasion towards the urinary bladder, the small bowel, and the ovary. The final staging according to the TNM classification is pT4N0Mx.
The en bloc laparoscopic resection for the treatment of sigmoid colon cancer, engaging the adjacent organs, is indicated and feasible, with surgical results, comparable with a conventional surgical intervention at the same volume.
在全球和区域范围内，腹腔镜结肠手术越来越多地取代了传统的结肠手术。许多随机研究表明，腹腔镜结肠手术在术后住院时间更短、恢复更快以及生存指标和复发频率相同方面具有优势。对于局部晚期结肠癌病例，整块切除是实现R0切除的最安全方法。肿瘤块向相邻结构的生长在大约50%的病例中表现为组织学肿瘤浸润。文献中描述的用于治疗结直肠癌的腹腔镜整块切除病例有所增加。在本报告中，我们展示了一例亚狭窄乙状结肠癌的临床病例，以及术中发现肿瘤浸润至一段小肠袢、部分膀胱、左侧输卵管和左侧附件。对于该患者，根据所谓的“腹腔镜非接触技术”进行了肿瘤形成的腹腔镜整块切除。尽管检查方法有所进步，但仍有大约15 - 20%的结直肠癌病例处于T4期，伴有相邻器官受累（1）。
一名67岁女性因亚狭窄乙状结肠病变、贫血综合征入院，结肠镜检查确诊为腺癌。内镜检查显示距肛缘25 cm处有腔内肿瘤，术前检查未发现任何继发性病变或其他器官侵犯。
放置四个腹部套管针。腹腔镜探查腹腔发现一个结肠肿块，怀疑侵犯一段小肠袢、部分膀胱、左侧输卵管和左侧卵巢。将肿瘤形成部分连同左侧输卵管和卵巢、膀胱及一段小肠袢整块切除。采用腹腔镜手工技术进行结直肠吻合。对吻合口进行了气密性测试。通过扩大5 mm耻骨上套管针取出标本。
平均手术时间为285分钟，失血300 ml。患者术后第5天出院。组织学结果证实肿瘤侵犯膀胱、小肠和卵巢。根据TNM分类的最终分期为pT4N0Mx。
对于侵犯相邻器官的乙状结肠癌，腹腔镜整块切除是可行的，其手术效果与相同范围的传统手术相当。
